Failure to Prevent Falls Results in Resident Injuries
Penalty
Summary
The facility failed to implement effective interventions to prevent falls for two residents, resulting in serious injuries. Resident 4, who had a history of dementia, anoxic brain damage, and repeated falls, was found on the floor with a hematoma after being left unattended by staff. Despite being on 1:1 supervision, the resident experienced multiple falls, including one where the assigned aide left her unsupervised to assist another resident. The facility did not revise or enhance fall prevention measures following these incidents. Resident 3, who had severe cognitive impairment and a history of falls, also experienced multiple falls resulting in injuries. The resident was found on the floor with a skin tear after sliding from her wheelchair, and later sustained a forehead and nasal laceration after falling forward from her wheelchair. The facility failed to provide consistent supervision and did not implement effective interventions to prevent further falls with injury for this resident. The facility's lack of effective fall prevention and supervision practices led to repeated falls and actual harm to both residents. There was no documented evidence of revised or enhanced interventions to address the ongoing fall risks and behavioral symptoms of the residents involved.